Provider Demographics
NPI:1962845131
Name:MARIN CITY HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:MARIN CITY HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MUHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYVON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-339-8813
Mailing Address - Street 1:630 DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-1107
Mailing Address - Country:US
Mailing Address - Phone:415-339-8813
Mailing Address - Fax:415-339-8814
Practice Address - Street 1:1601 2ND ST
Practice Address - Street 2:SUITE 108
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2712
Practice Address - Country:US
Practice Address - Phone:415-339-8813
Practice Address - Fax:415-339-8814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-08
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000861261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA751162Medicare Oscar/Certification
CA551117Medicare Oscar/Certification